<div class="consulFormation">
    <div class="consulHeader">患者信息</div>
    <div class="row">
        <div class="col-sm-4">
            <div class="col-sm-4"><span>患者姓名 <span style="color: red;">*</span></span></div>
            <div class="col-sm-8"><input id="customerName" name="customerName" placeholder="姓名可以某某代号" type="text" autocomplete="off"/></div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>性别 <span style="color: red;">*</span></span></div>
            <div class="col-sm-8">
                <select id="customerSex" name="customerSex">
                    <option value="1">男</option>
                    <option value="2">女</option>
                </select>
            </div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>年龄 <span style="color: red;">*</span></span></div>
            <div class="col-sm-8"><input id="customerAge" maxlength="2" name="customerAge" type="text" autocomplete="off" oninput="value=value.replace(/[^\d]/g,'')"></div>
        </div>
    </div>
    <div class="row">
        <div class="col-sm-4">
            <div class="col-sm-4"><span>身份证号</span></div>
            <div class="col-sm-8"><input id="idCard" name="idCard"  placeholder="特殊人群可使用B或H代替" type="text" autocomplete="off"/></div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>婚姻状况</span></div>
            <div class="col-sm-8">
                <select id="maritalStatus" name="maritalStatus" >
                    <option value="1">已婚</option>
                    <option value="2">未婚</option>
                    <option value="3">离异</option>
                    <option value="3">离异再婚</option>
                </select>
            </div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>生日</span></div>
            <div class="col-sm-8">
                <input type="text" autocomplete="off" placeholder="请选择出生年月日" id="birthday" onclick="laydate({istiem:true,format:'YYYY-MM-DD',choose:checkDate})">
            </div>
        </div>
    </div>
    <div class="row">
        <div class="col-sm-4">
            <div class="col-sm-4"><span>体重(kg)</span></div>
            <div class="col-sm-8"><input id="personWeight" maxlength="3" name="personWeight" type="text" autocomplete="off" oninput="value=value.replace(/[^\d]/g,'')"/></div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>身高(cm)</span></div>
            <div class="col-sm-8"><input id="personHeight" maxlength="3" name="personHeight" type="text" autocomplete="off" oninput="value=value.replace(/[^\d]/g,'')"/></div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>BMI</span></div>
            <div class="col-sm-8"><input id="BMI" name="BMI" type="text" autocomplete="off"/></div>
        </div>
    </div>
    <div class="row">
        <div class="col-sm-4">
            <div class="col-sm-4"><span>国籍</span></div>
            <div class="col-sm-8">
                <select id="nationality" name="nationality" >
                    <option value="1">中国</option>
                    <option value="2">美国</option>
                </select>
            </div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>民族</span></div>
            <div class="col-sm-8">
                <select id="nation" name="nation" >
                    <option value="1">汉族</option>
                    <option value="2">傣族</option>
                </select>
            </div>
        </div>
    </div>
    <div class="row">
        <div class="col-sm-4">
            <div class="col-sm-4"><span>医保类型</span></div>
            <div class="col-sm-8">
                <select id="insuranceState" name="insuranceState">
                    <option value="1">职工医保</option>
                    <option value="2">社会医保</option>
                </select>
            </div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>医保卡号</span></div>
            <div class="col-sm-8"><input id="medicalInsurance" name="medicalInsurance" type="text" autocomplete="off"/></div>
        </div>
    </div>
    <div class="row">
        <div class="col-sm-4">
            <div class="col-sm-4"><span>职业</span></div>
            <div class="col-sm-8"><input type="text" id="occupation" name="occupation" autocomplete="off"></div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>地址</span></div>
            <div class="col-sm-8"><input type="text" id="address" name="address" autocomplete="off"/></div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>入院时间 <span style="color: red;">*</span></span></div>
            <div class="col-sm-8">
                <input type="text" placeholder="请选择入院时间" autocomplete="off" id="hospitalizedTime" onclick="laydate({istiem:true,format:'YYYY-MM-DD hh:mm:ss',choose:checkDate})"></div>
        </div>
    </div>
    <div class="row">
        <div class="col-sm-4">
            <div class="col-sm-4"><span>就诊科室 <span style="color: red;">*</span></span></div>
            <div class="col-sm-8"><input type="text" id="medicalDepartment" name="medicalDepartment" autocomplete="off"/></div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>就诊类型</span></div>
            <div class="col-sm-8">
                <select id="medicalType" name="medicalType">
                    <option value="1">初诊</option>
                    <option value="2">复诊</option>
                </select>
            </div>
        </div>
        <div class="col-sm-4">
            <div class="col-sm-4"><span>牙位 <span style="color: red;">*</span></span></div>
            <div class="col-sm-8" id="projectListInfo">
                <div id="toothBox" class="toothBox" style="display: flex;flex-direction: column;flex: 1;height: 30px;width: 80%;">
                    <div style="flex: 1;display: flex;border-bottom: 1px solid #999999;line-height: 14px;">
                        <div id="leftUp" class="leftUp" style="flex: 1;border-right: 1px solid #999999;text-align: right;padding-right: 5px;"></div>
                        <div id="rightUp" class="rightUp" style="flex: 1;padding-left: 5px;text-align: left;"></div>
                    </div>
                    <div style="flex: 1;display: flex;line-height: 14px;">
                        <div id="leftDown" class="leftDown" style="flex: 1;border-right: 1px solid #999999;text-align: right;padding-right: 5px;"></div>
                        <div id="rightDown" class="rightDown" style="flex: 1;padding-left: 5px;text-align: left;"></div>
                    </div>
                </div>
            </div>
        </div>
    </div>
    <div class="row">
        <div class="col-sm-12">
            <div>备注</div>
            <textarea name="remarks" id="remarks" placeholder="字符限制2000" style="height: 120px;"></textarea>
        </div>
    </div>
    @layout("/common/_noneBox.html"){
    @}
</div>